1. Health Care Systems and Reimbursement
KNH 413 MNT II
Health Care Systems and Reimbursement

2. Overview Health Care Facilities in the U.S.
Preventive & Primary Health Care Services
Secondary & Tertiary Care
Restorative Care
Long-Term Care

4. Health Insurance
© 2007 Thomson - Wadsworth

6. © 2007 Thomson - Wadsworth

7. Providers of Public Insurance
Centers of Medicare & Medicaid Services
Department of Veterans Affairs
Public Health Services
Indian Health Service
Department of Defense
Civilian Health & Medical Program of the Uniformed Services
CHAMPUS
Public hospitals & community health centers
State & local public health programs

8. Medicare 1965 Title XVIII of Social Security Act
Administered by CMS of Department of Health & Human Services

9. Eligibility 65 years of age or older
Any age with end-stage renal disease
Eligible for Social Security or Railroad Retirement Board disability benefits up to 24 months
Medicare-covered government employment prior to retirement

10. Medicare Part A Hospital Insurance
Inpatient hospital, skilled nursing facility, & some home health
Deductibles & coinsurance fees
Hospital inpatient charges reimbursed according to prospective payment system (PPS)
Diagnosis-related groups (DRGs)

11. Medicare Part B Medical insurance Optional program
Provides benefits for
Eligible physician services
Outpatient hospital services
Certain home health services
Durable medical equipment
Nutrition
Medical Nutrition Therapy
Current procedural terminology (CMT)
Enrolled Medicare MNT providers bill for
Diabetes mellitus
Nondialysis kidney disease
Post-kidney transplant

12. Medicare savings after 3 years of reimbursement of nutrition services
© 2007 Thomson - Wadsworth

13. Coverage Gaps Prescription drug coverage
Skilled nursing & long-term institutional care > 100 days
Medicare Modernization Act of 2003
Optional coverage
Drug discount cards/prescription drug plans
Additional preventive benefits
Medigap Policy
Supplemental policy from private insurance companies

14. Medicaid Entitlement program Joint state & federal program
1965 Title XIX of the Social Security Act

15. Eligibility Low incomes
Certain pregnant women & children with low incomes
Older adults, the blind & people with disabilities
Members of families with dependent children in which one parent is absent, incapacitated or unemployed

16. SCHIP State Children’s Health Insurance Program
Title XXI in the Balanced Budget Act of 1997
Children of working families with incomes too high to qualify for Medicaid but too low to afford private health insurance

17. Coverage Inpatient & outpatient hospital services
Physicians’ surgical & medical services
Laboratory
X-ray services
Well baby/child care services

18. Percentage of Uninsured in U.S.

19. Elderly needing long-term care

20. Health Care Reform Success of health care system Challenges Cost
Quality
Access
Challenges
Accessible to all
Contain costs
Provide nursing home care
Ensure that Medicare & Medicaid can serve eligible people

21. © 2007 Thomson - Wadsworth

22. National health expenditures in billions of dollars, 1960-2002
© 2007 Thomson - Wadsworth

26. © 2007 Thomson - Wadsworth